Claims workbench/CLM-2026-006100

Institutional claim · UB-04 · EDI 837I

CLM-2026-006100

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-10 to 2026-08-12 at inpatient hospital (POS 21). Received 2026-08-21.

PendedOut of networkIdentity on hold: CASE-004121

Billed

$48,364.00

1 line

Allowed

$21,763.80

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Joan Lane
Member ID: none on golden record
Date of birth: —
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-400863
Relationship: Spouse, Plano, TX

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3024134405
Network: Out of network
Rendering NPI: 5800295359
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: PA2026932331 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	27447 rev 0360	Total knee arthroplasty	—	1	1	$48,364.00	$21,763.80	—	—	PendedIDQ
Totals						$48,364.00	$21,763.80	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-632719
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-08-10 to 2026-08-13
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-004121; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 9 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026932331 on file for 27447.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Review	HIGH	Billed $48,364.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2026-08-12 16:46
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
SystemSystem: Claims system2026-08-21 03:35
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-21 10:09
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026932331_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-08-10 to 2026-11-08.
Itemized billitemized_PA-632719.pdf8 pages
Itemised statement totalling $48364.00 across 1 line.
Medical recordrecords_PA-632719.pdf7 pages
Discharge summary and operative report.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-004121; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $48,364.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

ApprovedHIGHscenario: High dollar

Above auto-pay ceiling; payable once an examiner signs off.

Review queue Member identity